Integrating the complexity of healthcare improvement with implementation science: a longitudinal qualitative case study

Implementing paediatric appropriate use criteria for endotracheal suction to reduce complications in mechanically ventilated children with respiratory infections

BACKGROUND

Endotracheal suction is used to maintain endotracheal tube patency. There is limited guidance to inform clinical practice for children with respiratory infections.

OBJECTIVE

The objective of this study was to determine whether implementation of a paediatric endotracheal suction appropriate use guideline Paediatric AirWay Suction (PAWS) is associated with an increased use of appropriate and decreased use of inappropriate suction interventions.

METHODS

A mixed-method, pre-implementation-post-implementation study was conducted between September 2021 and April 2022. Suction episodes in mechanically ventilated children with a respiratory infection were eligible. Using a structured approach, we implemented the PAWS guideline in a single paediatric intensive care unit. Evaluation included clinical (e.g., suction intervention appropriateness), implementation (e.g., acceptability), and cost outcomes (implementation costs). Associations between implementation of the PAWS guideline and appropriateness of endotracheal suction intervention use were investigated using generalised linear models.

RESULTS

Data from 439 eligible suctions were included in the analysis. Following PAWS implementation, inappropriate endotracheal tube intervention use reduced from 99% to 58%, an absolute reduction (AR) of 41% (95% confidence interval [CI]: 25%, 56%). Reductions were most notable for open suction systems (AR: 48%; 95% CI: 30%, 65%), 0.9% sodium chloride use (AR: 23%; 95% CI: 8%, 38%) and presuction and postsuction manual bagging (38%; 95% CI: 16%, 60%, and 86%; 95% CI: 73%, 99%), respectively. Clinicians perceived PAWS as acceptable and suitable for use.

CONCLUSIONS

Implementation of endotracheal tube suction appropriate use guidelines in a mixed paediatric intensive care unit was associated with a large reduction in inappropriate suction intervention use in paediatric patients with respiratory infections.

Using Implementation Science in Nursing Research

OBJECTIVES

Clinical research continues to build knowledge that can potentially improve clinical and health service outcomes; however, integrating evidence into routine care is challenging, resulting in a knowledge practice gap. The field of implementation science is a resource available for nurses to translate evidence into their practice. This article aims to provide nurses with an overview of implementation science, illustrate its value integrating evidence into practice, and show how it can be applied with high rigor in nursing research practice.

DATA SOURCES

A narrative synthesis of the implementation science literature was conducted. A series of case studies were purposively selected to demonstrate the application of commonly used implementation theories, models, and frameworks across health care settings relevant to nursing. These case studies demonstrate how the theoretical framework was applied and how the outcomes of the work reduced the knowledge practice gap.

CONCLUSION

Implementation science theoretical approaches have been used by nurses and multidisciplinary teams to better understand the gap between knowledge and practice for better informed implementation. These can be used to understand the processes involved, identify the determinants at play, and undertake an effective evaluation.

IMPLICATIONS FOR NURSING PRACTICE

By using implementation science research practice, nurses can also build a strong foundation of evidence about nursing clinical practice. As an approach, implementation science is practical and can optimize the valuable nursing resource.

Implementation of a Statewide Web-Based Caregiver Resource Information System (CareNav): Mixed Methods Study

BACKGROUND

With the aging population, family caregivers provide increasingly complex and intense care for older adults and persons with disabilities. There is growing interest in developing community-based services to support family caregivers. Caregiving occurs around the clock, and caregivers face challenges in accessing community-based services at convenient times owing to the demands of care. Web-based resources hold promise for accessible real-time support. CareNav (TM), a caregiver resource information system, is a web-based platform designed to support real-time universal caregiver assessment, a record of client encounters, development of a care plan, tailored information and resource content, access to web-based caregiver resources, the capacity to track service authorization and contracts, and secure communications. The assessment includes needs and health conditions of both the care recipient and caregiver; current resources; and priorities for support, information, and referral. In 2019, the California Department of Health Care Services funded the 11 nonprofit California Caregiver Resource Centers (CRCs) to expand and improve family caregiver services and enhance CRC information technology services. Deployment of a statewide information system offered a unique opportunity to examine structures and processes facilitating implementation, providing feedback to the sites as well as lessons learned for similar projects in the future.

OBJECTIVE

The aim of this paper was to describe the statewide implementation of the comprehensive CareNav system using the Consolidated Framework for Implementation Research as an organizing structure for synthesizing the evaluation.

METHODS

This mixed methods study used two major approaches to evaluate the implementation process: a survey of all staff who completed training (n=82) and in-depth qualitative interviews with 11 CRC teams and 3 key informants (n=35). We initially analyzed interview transcripts using qualitative descriptive methods and then identified subthemes and relationships among ideas, mapping the findings to the Consolidated Framework for Implementation Research.

RESULTS

We present findings on the outer setting, inner setting, characteristics of the intervention, characteristics of the staff, and the implementation process. The critical elements for success were leadership, communication, harmonization of processes across sites, and motivation to serve clients in more accessible and convenient ways.

CONCLUSIONS

These findings have implications for technology deployment in diverse community-based agencies that aspire to enhance web-based services.